Portal de Periódicos da CAPES

Bare metal stent infections: Case report and review of the literature

2007; Elsevier BV; Volume: 46; Issue: 4 Linguagem: Inglês

10.1016/j.jvs.2007.05.043

1097-6809

Melissa E. Hogg, Brian G. Peterson, William H. Pearce, Mark D. Morasch, Melina R. Kibbe,

Aortic aneurysm repair treatments

Infection of bare metal stents in the vasculature is rare, but associated with significant morbidity and mortality. We report two cases of bare metal stent infections and review the literature regarding infected bare metal stents with respect to risk factors, pathophysiology, diagnosis, treatment, and prevention. Overall, this article highlights the need to have a high index of suspicion of bare metal stent infection, since prompt diagnosis and treatment can ultimately decrease the morbidity and mortality associated with this devastating problem. Infection of bare metal stents in the vasculature is rare, but associated with significant morbidity and mortality. We report two cases of bare metal stent infections and review the literature regarding infected bare metal stents with respect to risk factors, pathophysiology, diagnosis, treatment, and prevention. Overall, this article highlights the need to have a high index of suspicion of bare metal stent infection, since prompt diagnosis and treatment can ultimately decrease the morbidity and mortality associated with this devastating problem. Percutaneous transluminal angioplasty (PTA) and endovascular stent placement in the peripheral vasculature is becoming a prevalent treatment option for atherosclerotic disease. Problems and complications associated with these procedures include puncture site hematoma, vessel thrombosis, distal embolization, arterial dissection, arterial rupture, failure of stent expansion, stent displacement, stent malposition, neurologic injury, and pseudoaneurysm formation.1Liu P. Dravid V. Freiman D. Zegel H. Weinberg D. Persistent iliac endarteritis with pseudoaneurysm formation following balloon-expandable stent placement.Cardiovasc Intervent Radiol. 1995; 18: 39-42Crossref PubMed Scopus (22) Google Scholar, 2Long A.L. Page P.E. Raynaud A.C. Beyssen B.M. Fiessinger J.N. Ducimetiere P. et al.Percutaneous iliac artery stent: angiographic long-term follow-up.Radiology. 1991; 180: 771-778PubMed Google Scholar, 3Palmaz J.C. Laborde J.C. Rivera F.J. Encarnacion C.E. Lutz J.D. Moss J.G. Stenting of the iliac arteries with the Palmaz stent: experience from a multicenter trial.Cardiovasc Intervent Radiol. 1992; 15: 291-297Crossref PubMed Scopus (275) Google Scholar, 4Pruitt A. Dodson T.F. Najibi S. Thourani V. Sherman A. Cloft H. et al.Distal septic emboli and fatal brachiocephalic artery mycotic pseudoaneurysm as a complication of stenting.J Vasc Surg. 2002; 36: 625-628Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 5Schachtrupp A. Chalabi K. Fischer U. Herse B. Septic endarteritis and fatal iliac wall rupture after endovascular stenting of the common iliac artery.Cardiovasc Surg. 1999; 7: 183-186Crossref PubMed Scopus (16) Google Scholar, 6Therasse E. Soulez G. Cartier P. Passerini L. Roy P. Bruneau L. et al.Infection with fatal outcome after endovascular metallic stent placement.Radiology. 1994; 192: 363-365PubMed Google Scholar However, infection of bare metal stents in the peripheral vasculature is not well-reported. Since a report by Chalmers et al7Chalmers N. Eadington D.W. Gandanhamo D. Gillespie I.N. Ruckley C.V. Case report: infected false aneurysm at the site of an iliac stent.Br J Radiol. 1993; 66: 946-948Crossref PubMed Scopus (70) Google Scholar in 1993 of a case of arteritis following placement of a Palmaz stent (Cordis, Miami Lakes, Fla) in the right common iliac artery (CIA), only scattered case reports of peripheral bare metal stent infections have been published over the past 20 years (Table).1Liu P. Dravid V. Freiman D. Zegel H. Weinberg D. Persistent iliac endarteritis with pseudoaneurysm formation following balloon-expandable stent placement.Cardiovasc Intervent Radiol. 1995; 18: 39-42Crossref PubMed Scopus (22) Google Scholar, 4Pruitt A. Dodson T.F. Najibi S. Thourani V. Sherman A. Cloft H. et al.Distal septic emboli and fatal brachiocephalic artery mycotic pseudoaneurysm as a complication of stenting.J Vasc Surg. 2002; 36: 625-628Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 5Schachtrupp A. Chalabi K. Fischer U. Herse B. Septic endarteritis and fatal iliac wall rupture after endovascular stenting of the common iliac artery.Cardiovasc Surg. 1999; 7: 183-186Crossref PubMed Scopus (16) Google Scholar, 6Therasse E. Soulez G. Cartier P. Passerini L. Roy P. Bruneau L. et al.Infection with fatal outcome after endovascular metallic stent placement.Radiology. 1994; 192: 363-365PubMed Google Scholar, 7Chalmers N. Eadington D.W. Gandanhamo D. Gillespie I.N. Ruckley C.V. Case report: infected false aneurysm at the site of an iliac stent.Br J Radiol. 1993; 66: 946-948Crossref PubMed Scopus (70) Google Scholar, 8Rees C.R. Palmaz J.C. Becker G.J. Ehrman K.O. Richter G.M. Noeldge G. et al.Palmaz stent in atherosclerotic stenoses involving the ostia of the renal arteries: preliminary report of a multicenter study.Radiology. 1991; 181: 507-514PubMed Google Scholar, 9Quinn S.F. Schuman E.S. Hall L. Gross G.F. Uchida B.T. Standage B.A. et al.Venous stenoses in patients who undergo hemodialysis: treatment with self-expandable endovascular stents.Radiology. 1992; 183: 499-504PubMed Google Scholar, 10Gunther H.U. Strupp G. Volmar J. von Korn H. Bonzel T. Stegmann T. [Coronary stent implantation: infection and abscess with fatal outcome].Z Kardiol. 1993; 82: 521-525PubMed Google Scholar, 11Guest S.S. Kirsch C.M. Baxter R. Sorooshian M. Young J. Infection of a subclavian venous stent in a hemodialysis patient.Am J Kidney Dis. 1995; 26: 377-380Abstract Full Text PDF PubMed Scopus (27) Google Scholar, 12Deiparine M.K. Ballard J.L. Taylor F.C. Chase D.R. Endovascular stent infection.J Vasc Surg. 1996; 23: 529-533Abstract Full Text PDF PubMed Scopus (66) Google Scholar, 13Gordon G.I. Vogelzang R.L. Curry R.H. McCarthy W.J. Nemcek Jr, A.A. Endovascular infection after renal artery stent placement.J Vasc Interv Radiol. 1996; 7: 669-672Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 14Leroy O. Martin E. Prat A. Decoulx E. Georges H. Guilley J. et al.Fatal infection of coronary stent implantation.Cathet Cardiovasc Diagn. 1996; 39 (discussion 171): 168-170Crossref PubMed Scopus (50) Google Scholar, 15Weinberg D.J. Cronin D.W. Baker Jr., A.G. Infected iliac pseudoaneurysm after uncomplicated percutaneous balloon angioplasty and (Palmaz) stent insertion: a case report and literature review.J Vasc Surg. 1996; 23: 162-166Abstract Full Text PDF PubMed Scopus (44) Google Scholar, 16Hoffman A.I. Murphy T.P. Septic arteritis causing iliac artery rupture and aneurysmal transformation of the distal aorta after iliac artery stent placement.J Vasc Interv Radiol. 1997; 8: 215-219Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 17Bunt T.J. Gill H.K. Smith D.C. Taylor F.C. Infection of a chronically implanted iliac artery stent.Ann Vasc Surg. 1997; 11: 529-532Abstract Full Text PDF PubMed Scopus (43) Google Scholar, 18Bouchart F. Dubar A. Bessou J.P. Redonnet M. Berland J. Mouton-Schleifer D. et al.Pseudomonas aeruginosa coronary stent infection.Ann Thorac Surg. 1997; 64: 1810-1813Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 19Deitch J.S. Hansen K.J. Regan J.D. Burkhart J.M. Ligush Jr., J. Infected renal artery pseudoaneurysm and mycotic aortic aneurysm after percutaneous transluminal renal artery angioplasty and stent placement in a patient with a solitary kidney.J Vasc Surg. 1998; 28: 340-344Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 20DeMaioribus C.A. Anderson C.A. Popham S.S. Yeager T.D. Cordts P.R. Mycotic renal artery degeneration and systemic sepsis caused by infected renal artery stent.J Vasc Surg. 1998; 28: 547-550Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 21Muller G. Stockmann H. Markert U. Heise S. [The infected arterial stent].Chirurg. 1998; 69: 872-876Crossref PubMed Scopus (8) Google Scholar, 22Grewe P.H. Machraoui A. Deneke T. Muller K.M. Suppurative pancarditis: a lethal complication of coronary stent implantation.Heart. 1999; 81: 559PubMed Google Scholar, 23Giannoukas D.D. Tsetis D.K. Touloupakis E. Alamanos E. Karniadakis S. Korakas P. et al.Suppurative bacterial endarteritis after percutaneous transluminal angioplasty, stenting and thrombolysis for femoropopliteal arterial occlusive disease.Eur J Vasc Endovasc Surg. 1999; 18: 455-457Abstract Full Text PDF PubMed Scopus (9) Google Scholar, 24Bukhari R.H. Muck P.E. Schlueter F.J. Annenberg A.J. Roedersheimer L.R. Paget D.S. et al.Bilateral renal artery stent infection and pseudoaneurysm formation.J Vasc Interv Radiol. 2000; 11: 337-341Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 25Naddour F. Yount Jr., R.D. Quintal R.E. Successful conservative treatment of an infected central venous stent.Catheter Cardiovasc Interv. 2000; 51: 196-198Crossref PubMed Scopus (14) Google Scholar, 26Rensing B.J. van Geuns R.J. Janssen M. Oudkerk M. de Feyter P.J. Stentocarditis.Circulation. 2000; 101: E188-E190Crossref PubMed Google Scholar, 27Myles O. Thomas W.J. Daniels J.T. Aronson N. Infected endovascular stents managed with medical therapy alone.Catheter Cardiovasc Interv. 2000; 51: 471-476Crossref PubMed Google Scholar, 28Malek A.M. Higashida R.T. Reilly L.M. Smith W.S. Kang S.M. Gress D.R. et al.Subclavian arteritis and pseudoaneurysm formation secondary to stent infection.Cardiovasc Intervent Radiol. 2000; 23: 57-60Crossref PubMed Scopus (28) Google Scholar, 29Dosluoglu H.H. Curl G.R. Doerr R.J. Painton F. Shenoy S. Stent-related iliac artery and iliac vein infections: Two unreported presentations and review of the literature.J Endovasc Ther. 2001; 8: 202-209Crossref PubMed Scopus (32) Google Scholar, 30Walton K.B. Hudenko K. D'Ayala M. Toursarkissian B. Aneurysmal degeneration of the superficial femoral artery following stenting: an uncommon infectious complication.Ann Vasc Surg. 2003; 17: 445-448Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 31Liu J.C. Cziperle D.J. Kleinman B. Loeb H. Coronary abscess: a complication of stenting.Catheter Cardiovasc Interv. 2003; 58: 69-71Crossref PubMed Scopus (28) Google Scholar, 32Alfonso F. Moreno R. Vergas J. Fatal infection after rapamycin eluting coronary stent implantation.Heart. 2005; 91: e51Crossref PubMed Scopus (36) Google Scholar, 33Kaviani A. Ouriel K. Kashyap V.S. Infected carotid pseudoaneurysm and carotid-cutaneous fistula as a late complication of carotid artery stenting.J Vasc Surg. 2006; 43: 379-382Abstract Full Text Full Text PDF PubMed Scopus (27) Google ScholarTableCase reports of infected bare metal stentsAuthorDateVessel locationStentTime to presentationSigns and symptomsOrganismProphylactic antibioticsRees8Rees C.R. Palmaz J.C. Becker G.J. Ehrman K.O. Richter G.M. Noeldge G. et al.Palmaz stent in atherosclerotic stenoses involving the ostia of the renal arteries: preliminary report of a multicenter study.Radiology. 1991; 181: 507-514PubMed Google Scholar1991Renal arteryPalmaz3 daysUnknownUnknownUnknownQuinn9Quinn S.F. Schuman E.S. Hall L. Gross G.F. Uchida B.T. Standage B.A. et al.Venous stenoses in patients who undergo hemodialysis: treatment with self-expandable endovascular stents.Radiology. 1992; 183: 499-504PubMed Google Scholar1992Unknown veinGianturco2 daysUnknown (patient signed out against medical advice)UnknownNone, but after this complication the authors startedChalmers7Chalmers N. Eadington D.W. Gandanhamo D. Gillespie I.N. Ruckley C.V. Case report: infected false aneurysm at the site of an iliac stent.Br J Radiol. 1993; 66: 946-948Crossref PubMed Scopus (70) Google Scholar1993Right CIAPalmaz2 daysGroin pain, fevers, edema, leukocytosisStaphylococcus aureusUnknownGunther10Gunther H.U. Strupp G. Volmar J. von Korn H. Bonzel T. Stegmann T. [Coronary stent implantation: infection and abscess with fatal outcome].Z Kardiol. 1993; 82: 521-525PubMed Google Scholar1993Right coronary arteryPalmaz-Schatz4 weeksFevers, malaise, pericardial effusion, leukocytosisStaphylococcus aureusUnknownTherasse6Therasse E. Soulez G. Cartier P. Passerini L. Roy P. Bruneau L. et al.Infection with fatal outcome after endovascular metallic stent placement.Radiology. 1994; 192: 363-365PubMed Google Scholar1994Left CIA; right EIAPalmaz10 daysFever, chills, abdominal pain, leg pain, petechiaeStaphylococcus aureus and Staphylococcus epidermidisNoneLiu1Liu P. Dravid V. Freiman D. Zegel H. Weinberg D. Persistent iliac endarteritis with pseudoaneurysm formation following balloon-expandable stent placement.Cardiovasc Intervent Radiol. 1995; 18: 39-42Crossref PubMed Scopus (22) Google Scholar1995Bilateral CIAPalmaz2 daysGroin pain, fevers, N/V, chills, abdominal pain, back painStaphylococcus aureusUnknownGuest11Guest S.S. Kirsch C.M. Baxter R. Sorooshian M. Young J. Infection of a subclavian venous stent in a hemodialysis patient.Am J Kidney Dis. 1995; 26: 377-380Abstract Full Text PDF PubMed Scopus (27) Google Scholar1995Right subclavian veinWallstent24 daysFever, chills, malaise, delirium, right arm and shoulder edemaStaphylococcus aureusUnknownDeiparine12Deiparine M.K. Ballard J.L. Taylor F.C. Chase D.R. Endovascular stent infection.J Vasc Surg. 1996; 23: 529-533Abstract Full Text PDF PubMed Scopus (66) Google Scholar1996Right CIA, right CFA, re-PTA right EIAUnknown9 daysFever, groin pain, petechiae, leukocytosisStaphylococcus aureus and Escherichia coliUnknownGordon13Gordon G.I. Vogelzang R.L. Curry R.H. McCarthy W.J. Nemcek Jr, A.A. Endovascular infection after renal artery stent placement.J Vasc Interv Radiol. 1996; 7: 669-672Abstract Full Text PDF PubMed Scopus (20) Google Scholar1996Left renal arteryPalmaz10 daysFever, flank pain, nocturia, chillsBeta hemolytic streptococcusUnknownLeroy14Leroy O. Martin E. Prat A. Decoulx E. Georges H. Guilley J. et al.Fatal infection of coronary stent implantation.Cathet Cardiovasc Diagn. 1996; 39 (discussion 171): 168-170Crossref PubMed Scopus (50) Google Scholar1996Left anterior descendingPalmaz-Schatz7 daysFever, murmurPseudomonas aeruginosaUnknownWeinberg15Weinberg D.J. Cronin D.W. Baker Jr., A.G. Infected iliac pseudoaneurysm after uncomplicated percutaneous balloon angioplasty and (Palmaz) stent insertion: a case report and literature review.J Vasc Surg. 1996; 23: 162-166Abstract Full Text PDF PubMed Scopus (44) Google Scholar1996Bilateral CIAPalmaz2 daysFever, N/V, groin/abdominal pain, leukocytosis, petechiaeStaphylococcus aureusNoneHoffman16Hoffman A.I. Murphy T.P. Septic arteritis causing iliac artery rupture and aneurysmal transformation of the distal aorta after iliac artery stent placement.J Vasc Interv Radiol. 1997; 8: 215-219Abstract Full Text PDF PubMed Scopus (20) Google Scholar1997Right iliac arteryWallstents7 daysAbdominal pain, back pain, fever, edema, leg pain, mottled legStaphylococcus aureusUnknownBunt17Bunt T.J. Gill H.K. Smith D.C. Taylor F.C. Infection of a chronically implanted iliac artery stent.Ann Vasc Surg. 1997; 11: 529-532Abstract Full Text PDF PubMed Scopus (43) Google Scholar1997Left EIAPalmaz22 monthsSepsis, abdominal/groin pain, petechiaeStaphylococcus aureusUnknownBouchart18Bouchart F. Dubar A. Bessou J.P. Redonnet M. Berland J. Mouton-Schleifer D. et al.Pseudomonas aeruginosa coronary stent infection.Ann Thorac Surg. 1997; 64: 1810-1813Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar1997Left circumflexPalmaz-Schatz4 daysFevers, chills, chest pain, pericardial effusionPseudomonas aeruginosaUnknownDeitch19Deitch J.S. Hansen K.J. Regan J.D. Burkhart J.M. Ligush Jr., J. Infected renal artery pseudoaneurysm and mycotic aortic aneurysm after percutaneous transluminal renal artery angioplasty and stent placement in a patient with a solitary kidney.J Vasc Surg. 1998; 28: 340-344Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar1998Renal arteryUnknown3 monthsBack painMRSAUnknownDeMaioribus20DeMaioribus C.A. Anderson C.A. Popham S.S. Yeager T.D. Cordts P.R. Mycotic renal artery degeneration and systemic sepsis caused by infected renal artery stent.J Vasc Surg. 1998; 28: 547-550Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar1998Left renal arteryPalmaz14 daysFever, hypotension, leukocytosis, melena, abdominal/flank painStaphylococcus aureus (blood/wound) and Proteus mirabilis (urine)NoneMuller21Muller G. Stockmann H. Markert U. Heise S. [The infected arterial stent].Chirurg. 1998; 69: 872-876Crossref PubMed Scopus (8) Google Scholar1998Left CIAPalmaz12 daysFever, hypotension, tachycardia, leukocytosisStaphylococcus aureusUnknownGrewe22Grewe P.H. Machraoui A. Deneke T. Muller K.M. Suppurative pancarditis: a lethal complication of coronary stent implantation.Heart. 1999; 81: 559PubMed Google Scholar1999LADMicro-stent4 daysAcute myocardial infarction, fever, leucocytosis, myocardial abscessStaphylococcus aureusUnknownSchachtrupp5Schachtrupp A. Chalabi K. Fischer U. Herse B. Septic endarteritis and fatal iliac wall rupture after endovascular stenting of the common iliac artery.Cardiovasc Surg. 1999; 7: 183-186Crossref PubMed Scopus (16) Google Scholar1999Left CIASelf-adjusting nitinol angiomed10 daysFever, leukocytosis, malaise, chills, thigh pain, rashStaphylococcus aureusNoneGiannoukas23Giannoukas D.D. Tsetis D.K. Touloupakis E. Alamanos E. Karniadakis S. Korakas P. et al.Suppurative bacterial endarteritis after percutaneous transluminal angioplasty, stenting and thrombolysis for femoropopliteal arterial occlusive disease.Eur J Vasc Endovasc Surg. 1999; 18: 455-457Abstract Full Text PDF PubMed Scopus (9) Google Scholar1999Left SFA, left popliteal arteryStrecker and Palmaz2 weeksClaudication, cellulitis, fever, thigh painMRSANoneBukhari24Bukhari R.H. Muck P.E. Schlueter F.J. Annenberg A.J. Roedersheimer L.R. Paget D.S. et al.Bilateral renal artery stent infection and pseudoaneurysm formation.J Vasc Interv Radiol. 2000; 11: 337-341Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar2000Bilateral renal arteriesPalmaz6 monthsHypertensive crisis, back pain, leukocytosisUnknownAncefNaddour25Naddour F. Yount Jr., R.D. Quintal R.E. Successful conservative treatment of an infected central venous stent.Catheter Cardiovasc Interv. 2000; 51: 196-198Crossref PubMed Scopus (14) Google Scholar2000Right innominate vein and right subclavian veinWallstent within previous Wallstent20 daysFever, chills, weakness, anorexia, shoulder pain, arm swellingStaphylococcus aureusUnknownRensing26Rensing B.J. van Geuns R.J. Janssen M. Oudkerk M. de Feyter P.J. Stentocarditis.Circulation. 2000; 101: E188-E190Crossref PubMed Google Scholar2000Obtuse marginal and right coronary arteryUnknown4 daysFevers, chills, malaise, chest painStaphylococcus aureusUnknownMyles27Myles O. Thomas W.J. Daniels J.T. Aronson N. Infected endovascular stents managed with medical therapy alone.Catheter Cardiovasc Interv. 2000; 51: 471-476Crossref PubMed Google Scholar2000Left subclavian arteryPalmaz2 daysFever, rigors, lethargy, delirium, subclavian, bruit, leukocytosisStaphylococcus aureusNoneMyles27Myles O. Thomas W.J. Daniels J.T. Aronson N. Infected endovascular stents managed with medical therapy alone.Catheter Cardiovasc Interv. 2000; 51: 471-476Crossref PubMed Google Scholar2000Bilateral CIA and LADPalmaz4 daysChills, sweats, fever, leukocytosisStaphylococcus aureusNoneMalek28Malek A.M. Higashida R.T. Reilly L.M. Smith W.S. Kang S.M. Gress D.R. et al.Subclavian arteritis and pseudoaneurysm formation secondary to stent infection.Cardiovasc Intervent Radiol. 2000; 23: 57-60Crossref PubMed Scopus (28) Google Scholar2000Left subclavian arteryPalmaz and multilink premounted stent6 daysFever, chills, arm pain, tender venous cord, leukocytosis, skin lesions in armStaphylococcus aureusUnknownDosluoglu29Dosluoglu H.H. Curl G.R. Doerr R.J. Painton F. Shenoy S. Stent-related iliac artery and iliac vein infections: Two unreported presentations and review of the literature.J Endovasc Ther. 2001; 8: 202-209Crossref PubMed Scopus (32) Google Scholar2001Right EIA and right CIAPalmazMany monthsAbdominal pain, hip pain, fever, malaise, leukocytosis, edemaMRSANoneDosluoglu29Dosluoglu H.H. Curl G.R. Doerr R.J. Painton F. Shenoy S. Stent-related iliac artery and iliac vein infections: Two unreported presentations and review of the literature.J Endovasc Ther. 2001; 8: 202-209Crossref PubMed Scopus (32) Google Scholar2001Left CIVPalmaz4 daysFever, chills, abdominal pain, edema, diarrheaStaphylococcus epidermisNonePruitt4Pruitt A. Dodson T.F. Najibi S. Thourani V. Sherman A. Cloft H. et al.Distal septic emboli and fatal brachiocephalic artery mycotic pseudoaneurysm as a complication of stenting.J Vasc Surg. 2002; 36: 625-628Abstract Full Text PDF PubMed Scopus (26) Google Scholar2002Right subclavian artery and brachiocephalic arteryTandem smart stents and Palmaz, respectively14 daysMalaise, erythematous macular lesions on arm/hand, arm edema, petechiae, right vision loss, finger gangrene, septic emboli to brainStaphylococcus aureusNoneWalton30Walton K.B. Hudenko K. D'Ayala M. Toursarkissian B. Aneurysmal degeneration of the superficial femoral artery following stenting: an uncommon infectious complication.Ann Vasc Surg. 2003; 17: 445-448Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar2003Left SFAUnknownMany monthsLeft medial calf abscess, pulsatile thigh massMRSAUnknownLiu31Liu J.C. Cziperle D.J. Kleinman B. Loeb H. Coronary abscess: a complication of stenting.Catheter Cardiovasc Interv. 2003; 58: 69-71Crossref PubMed Scopus (28) Google Scholar2003LADNIR18 daysFever, leukocytosis, chest pain, cardiac abscessStaphylococcus aureus, simulans, and capitisUnknownAlfonso32Alfonso F. Moreno R. Vergas J. Fatal infection after rapamycin eluting coronary stent implantation.Heart. 2005; 91: e51Crossref PubMed Scopus (36) Google Scholar2005Right coronary arteryRapamycin eluting2 daysFever, chills, malaiseStaphylococcus aureusUnknownKaviani33Kaviani A. Ouriel K. Kashyap V.S. Infected carotid pseudoaneurysm and carotid-cutaneous fistula as a late complication of carotid artery stenting.J Vasc Surg. 2006; 43: 379-382Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar2006Left ICACordis precise stent20 monthsCarotid cutaneous fistula with pulsatile mass, purulent drainage, hemorrhageBeta hemolytic streptococcusNonePresent report2007Left SFAUnknownUnknownRetroperitoneal hematoma, trashed footStaphylococcus aureusUnknownPresent report2007Bilateral SFAViabahn and Protégé1 weekFever, chills, sweats, knee swellingPseudomonas aeruginosaUnknownATA, anterior tibial artery; CFA, common femoral artery; CIA, common iliac artery; CIV, common iliac vein; EIA, external iliac artery; ICA, Internal carotid artery; LAD, left anterior descending; MRSA, methicillin resistant Staphylococcus aureus; N/V, nausea and vomiting; PTA, percutaneous transluminal angioplasty; SFA, superficial femoral artery. Open table in a new tab ATA, anterior tibial artery; CFA, common femoral artery; CIA, common iliac artery; CIV, common iliac vein; EIA, external iliac artery; ICA, Internal carotid artery; LAD, left anterior descending; MRSA, methicillin resistant Staphylococcus aureus; N/V, nausea and vomiting; PTA, percutaneous transluminal angioplasty; SFA, superficial femoral artery. Vascular graft infection is a well-described problem with a number of accepted standards for prevention and treatment. Currently, however, no such standards exist for managing bare metal stent infections. Furthermore, no consensus has been reached regarding the need for prophylactic antibiotics prior to stent placement. The type of sterile environment in which these procedures should be performed remains a question. In addition, the need for periprocedural antibiotics during other procedures that potentially cause transient bacteremia has not been standardized. Although uncommon, previous case reports have demonstrated the significant potential for associated morbidity that can be associated with bare metal stent infection. In this article, we report two cases from our institution and highlight important aspects of this difficult and dangerous problem. A 58-year-old male who previously underwent placement of nine bilateral lower extremity bare metal stents (right and left external iliac artery [EIA], right and left common iliac artery [CIA], two right and three left superficial femoral artery [SFA]) was transferred to our medical center with left lower extremity gangrene and necrosis of the left medial knee. He originally presented to the referring medical center 1 month earlier with worsening bilateral lower extremity claudication. He was diagnosed with left SFA stent occlusion and received tissue plasminogen activator (tPA). He was re-admitted several times for stent re-occlusion and underwent tPA three times. The last procedure was complicated by sepsis and a large retroperitoneal bleed. The patient was transferred to our medical center receiving piperacillin/tazobactam. Physical examination revealed costo-vertebral angle tenderness, flank ecchymosis, a palpable right femoral pulse, but no other palpable pulses in either lower extremity. Examination of the extremities also revealed left medial knee skin necrosis and dry gangrene of the left first and fifth toes. Laboratory studies revealed no leukocytosis. Blood cultures were positive for Staphylococcus aureus. A tagged white blood cell (WBC) scan localized to both thighs. A computed tomography (CT) scan showed: (1) aneurysmal dilation (3.6 cm × 3.4 cm) of the proximal left CIA with contrast filling the lumen outside the wall of the stent consistent with pseudoaneurysm formation and 10.0 cm × 10.7 cm retroperitoneal hematoma (Fig 1); (2) a fluid collection (2.8 cm × 2.9 cm) surrounding the proximal left SFA stent; and (3) a fluid collection with air surrounding the distal left SFA stent with extension into the vastus medialis (Fig 2).Fig 2Computed tomography scan demonstrating an enhanced fluid collection around left superficial femoral artery (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) He was taken to the operating room for removal of both CIA stents, the left EIA stent, and the proximal left SFA stent with ligation of the proximal left SFA. A bifurcated aortoiliac homograft was used to reconstruct the aortoiliac inflow. The patient returned to the operating room several days later for removal of the remaining infected left SFA stents, excision of the entire SFA, and creation of a left profunda femoral to above-knee popliteal artery bypass graft using orthograde greater saphenous vein through a lateral approach. Cultures from both surgeries were positive for Staphylococcus aureus. The patient was discharged home on a 6-week course of ampicillin/sulbactam and subsequently underwent a left foot transmetatarsal amputation. A 54-year-old male who previously underwent placement of bilateral lower extremity stents was transferred to our institution for evaluation and treatment of a septic right knee associated with Pseudomonas aeruginosa bacteremia. Five months prior to admission the patient underwent placement of three Viabahn stents (W.L. Gore, Flagstaff, Ariz). The next month, he underwent additional stenting of the distal right SFA with two bare metal nitinol Protégé stents (ev3 inc, Plymouth, Minn). Within one month, the patient developed symptoms of right knee swelling and pain. At the referring hospital, he was found to have Pseudomonas aeruginosa septic arthritis. The patient was treated with piperacillin/tazobactam and tobramycin sulfate, but eventually required arthroscopic incision and drainage of the right knee. One week after completion of an 8-week course of piperacillin/tazobactam and tobramycin sulfate, the symptoms recurred and he was transferred to our institution for further evaluation and treatment. On physical examination, the patient was afebrile, but had a right knee effusion and right calf edema. Pulse examination revealed palpable bilateral femoral and popliteal artery pulses, but no pulses distally. ABI of the right and left dorsalis pedis were 0.9 and 0.85, respectively. A tagged WBC scan demonstrated increased uptake in the thigh. A CT scan of the lower extremities revealed: (1) contiguous stenting along the entire right SFA; (2) a 9 mm × 22 mm fluid collection anterior to the distal aspect of the right SFA bare metal stent; and (3) soft tissue stranding along the entire SFA. Magnetic resonance angiography (MRA) of the lower extremities revealed a 9 mm × 22 mm fluid collection anterior to the distal aspect of the right SFA stent consistent with a pseudoaneurysm (Fig 3). The patient was taken to the operating room where the entire right SFA and popliteal artery were removed and reconstructed with a right femoral to anterior tibial artery bypass graft using orthograde greater saphenous vein. The right distal SFA was found to have a large pseudoaneurysm associated with purulent fluid surrounding the bare metal stent. Operative cultures were obtained, but were all negative. His postoperative recovery was unremarkable, and he was discharged to a rehabilitation institute with oral ciprofloxacin and wound vacuum assisted closure (VACs) (KCI, San Antonio, Tex) for his open thigh wounds. A thorough review of the literature was performed from 1966 to present and just over 30 case reports were found regarding infectious complications following placement of a bare metal stent (Table). Bare metal stents are commonly utilized for the treatment of coronary artery disease, renal artery stenosis, carotid artery stenosis, subclavian/brachiocephalic pathology, hemodialysis access sites, and lower extremity peripheral arterial occlusive disease. The majority of reports in the l